Examination of Witnesses (Questions 380-393)
MR KEN
JONES AND
MS JO
WEBBER
17 NOVEMBER 2008
Q380 Mr Betts: They do not do it
now.
Ms Webber: They do in terms of
practice post-commissioning.
Q381 Mr Betts: Who is on the PCT?
The PCT is not full of clinicians.
Ms Webber: The Professional Executive
Committee which is the part of the organisation that very clearly
looks at what the development plan is for the PCT and the way
in which services are improved, developed and delivered, includes
a range of clinicians.
Q382 Mr Betts: If we had all that
involvement by clinicians that we do now and, instead of being
appointed to a PCT, you had elected people, would that be a problem?
Ms Webber: I think you would have
to be very clear in the way in which you dealt with what can be
some quite single issue politics locally. For instance, closing
an A&E department or closing a maternity unit, and how you
would ensure that you got a range of people with a range of views,
if they were elected, to ensure that you had the discussions which
covered all of those issues in a fair and transparent way.
Q383 Mr Betts: Those decisions, by
and large, are decisions for hospital trusts rather than PCTs.
Ms Webber: No. PCTs commission
their services.
Q384 Chair: To use a different analogy,
a council will have to take decisions for example on closing schools
if the school age population is dropping and they are not able
to maintain standards. Why is closing a hospital any more difficult?
Ms Webber: Schools are exactly
the same. It is a very emotive subject and it requires a lot of
local consultation and a lot of local scrutiny as to how you do
that. I suppose the difference would be that the funding that
is involved in that hospital is very much essentially taxation
based, whereas a lot of the education funding may be from local
sources.
Mr Jones: In most police forces,
their authorities are already doing that. The professional advice
is given by the chief constable and commissioner and on the basis
of that strategic plans are commissioned and funding allocated.
How it plays out tactically is then down to people on the ground
at inspector level. We would argue that that is already happening.
How much access the public seeks to that is very different. Unless
there is a local issue that is controversial, people tend not
to get involved, but they certainly are beginning to be around
the precept issues, as you know. They are looking for more traction
over how those decisions are made. We would see the police authority
as a commissioning body following advice from the professionals.
Then we go away and deliver it.
Q385 Mr Betts: If the police authority
changed into something which was wholly elected, local councils
would have a role in that commissioning?
Mr Jones: Local councillors are
on the police authority now.
Q386 Mr Betts: It could be done at
a more local level because police authorities often cover a very
wide area.
Mr Jones: Yes, but we have a variation
in force sizes. Some of them are quite small. I think there is
much greater immediacy between the local democratically elected
councillors and their constituencies, even though they are seconded
by a district authority, and some of the larger ones where I think
the connection is less obvious.
Ms Webber: In terms of appointments,
we have done quite a bit of work with the Local Government Association
on how you might look at strengthening the scrutiny. One thing
we also looked at is why there should not be on appointment commission
panels local authority members to ensure that, when you are particularly
appointing non-executives for PCTs and for health trusts, there
is not a local authority voice in the selection of people.
Q387 Mr Betts: You might be thinking
the balance of power change revolves around a bit more than simply
having a local authority rep.
Ms Webber: Absolutely, but also
for a lot of PCT boards they do have as co-opted members cabinet
members from local authorities or other local councillors.
Q388 Anne Main: Forgive me if I am
putting the wrong interpretation on this but it appears from the
evidence you have given—and indeed the evidence that we
had previously from the ministers—that it is almost as if
the local councillors cannot be trusted not to be political and
that having someone faceless would be seen as being not so political.
Can I pose it to you that actually people who are faceless may
well be able to make more reckless decisions because they are
not accountable? Perhaps they would make a decision more quickly
or out of step with what the local population wants because nobody
is there, badgering them at their door, which is what makes a
politician political in the first place with regard to their public.
Could you think about that? Having a degree of politics in at
local level may actually be good. It seems to be suggested by
both of you that it is bad.
Mr Jones: I hope I have not given
that impression.
Ms Webber: I think the other thing
is the duty to consult, and PCTs take very seriously the duty
to involve patients and users of their services in both the development
of the way in which those services are commissioned and also in
terms of health providers in the development of for instance membership
schemes to ensure that there is an evaluation of the way in which
services are being delivered. I take your point about local politics
but I think there are also other ways in which local health services
try to make a direct engagement with them.
Q389 Dr Pugh: It is a bit of a broken
record, is it not, both from you and from the Health Minister?
What you keep saying all the time is that, yes, you have a duty
to consult; yes, there will be co-option; yes, there will be this
and that but, at the end of the day, neither you nor the Minister
have given the Committee a plausible argument that differentiates
health from the police and makes it clear that locally elected
representatives cannot make decisions here. There is not one,
is there? What is the killer argument that says it has to be different?
Ms Webber: For me, there is an
issue about who we are eventually accountable to. I think we are
accountable to the local population. We are developing ways of
ensuring that the local population is involved in both the commissioning—
Q390 Dr Pugh: But that is radically
implausible to suggest you do not want the local population to
elect people and thereby, by putting a block to that, you are
somehow more accountable to the local people.
Ms Webber: The evidence we have
had was that local people believed that the people who should
make decisions about their health services are clinicians working
locally with members of the—
Q391 Dr Pugh: I do not want to be
antagonistic about this but when you ask people, "Who do
you want to make decisions about your health care?" I would
much sooner it was an appropriately qualified physician than any
of us sitting round the table. If you ask me who is to make the
decision about where the police should go tonight and how they
should react, I would much sooner it was the local constable than
the people on the police authority. When it comes to setting the
strategic template which those organisations work from, it is
not convincing at all to say that the public say that because
in a sense they are answering a different question.
Ms Webber: We are already part
of the local strategic partnership.
Q392 Chair: I was going to ask you
whether you thought the Department of Health was fundamentally
more Stalinist than the Home Office. Actually, it seems to be
more: would you agree that the health economy as a whole is fundamentally
more Stalinist than the police and community safety partnership
as a whole? That is what the divide seems to be. It is not between
the departments. It is between health and policing.
Mr Jones: Given the taxpayer investment
annually in health, it dwarfs what we spend on criminal justice.
I think inevitably Government gets more interested and draws more
towards itself because it feels it is handling a massive risk.
I think that is what has happened. We have this organisation which
follows from that. Policing is probably only five per cent of
it.
Sir Paul Beresford: A very large
proportion of local government is social services. That is very
closely linked to health and it has the Department of Health peering
over its shoulder with a microscope.
Q393 Chair: Just to pursue this analogy:
these examples may be poorly chosen but the Soham murders for
example appear to be a bit of a fault in the police service and
killed two young—obviously the murderer killed them but
I do not buy that really, that policing is fundamentally less
important to people.
Mr Jones: It is not less important.
I did not mean to imply that. The other argument I would make
is that policing sprang from and is still accountable up to a
point to local communities in a way that probably the Health Service
did not post-1948. Elements of that are still around. People's
attachment to their local policing brand, their authority, is
pretty powerful compared to the health strategic architecture
which is totally different, in my view. That feeds the point earlier
about mergers. I think that came apart because of the strength
of local feelings against it, which was quite surprising. There
was a bottom up resistance to that.
Jim Dobbin: The Committee are
anxious to find out why in some instances there is a democratic
deficit in the system and to point to the fact that it would be
better if there were locally elected members to those organisations.
We are not naive enough to think that some of those people who
are appointed by the appointments commission are not political
appointments, because they are. If you look down the list locally,
I know who they are and where they came from. We all do. I think
that is the point we would like to highlight. They are not your
local experts, they might well have expertise in some things—
Chair: Thank you very much. This has
been a really interesting discussion. Thank you for your contribution.
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